AHEC of a Summer Health Careers Volunteer Program

Iberia Parish1

2016

AHEC of a Summer
Health Careers Volunteer Program

Application

DEADLINE: February 26, 2016

Submit Application to:

Charlene Broussard RN

618 Recreation Drive

New Iberia, La. 70560

337-519-0818

Note: In addition to on-line access, applications are being distributed in each parish by school system personnel.

Applications must be filled out by the student in blue or black ink. Please print or type.

Name: ______Parish:______

Address: ______ School:______
City, State, Zip: ______Current year in school: 10 11

Home Phone:(_____)______Gender: Male Female

Date of Birth: ______Age:______

Student Email Address: ______

Please print clearly

Please note: HRSA requires that AHECs report data on race and ethnicity for federal statistics, program administrative reporting, and civil rights compliance.

Race (check those that apply)

_____ American Indian or Alaska Native

_____ Asian (Chinese, Filipino, Japanese, Korean, Asian Indian or Thai)

_____ Asian (Any Asian other than those listed above)

_____ Black or African American

_____ Native Hawaiian or Other Pacific Islander

_____ Caucasian

Ethnicity (check one)

_____Hispanic or Latino(A person of Cuban, Mexican, Puerto Rican, South or Central

American, or other Spanish culture or origin)

_____Non-Hispanic

What isyour high school semester grade for Biology______General Science?______

List the name of all high school science classes which you have taken or are currently enrolled and indicate if honors or online:

______

Do you have reliable transportation to the program location? Yes_____ No_____

Parent/Guardian Names: ______

______

Parent/Guardian Addresses (if different from student’s)______

______

MotherFather

Parent/Guardian Work Phone ______

Parent/Guardian Home Phone ______

Parent/Guardian Cell Phone ______

Acceptance into the AHEC-of-A-Summer program requires a fee of $25 and a commitment of approximately 100 total hours of weekday volunteer service at designated health care facilities between May20thand June 3, 2016. Volunteers do NOT receive wages or salary through the AHEC-of-A-Summer program. Signing this application is an indication of your availability and commitment to participate in ALL scheduled AHEC-of-A- Summer activities. Moneyshould NOT be sent with this application.

Applicant signature: ______Date: ______

Parent/guardian signature: ______Date: ______

Return the completed application to the person designated below in a timely manner:

Charlene Broussard RN, AHEC Teacher IPCC CNA Instructor

618 Recreation Drive

New Iberia, La. 70560

______

This program is a cooperative service of the Southwest Louisiana Area Health Education Center, parish school boards, local hospitals, clinics, and other health care facilities and offices.

From time to time, students will be contacted by Southwest Louisiana AHEC as a follow-up to this experience

Iberia Parish1

Notice: Attached at the end of this application are instructions for Letters of Reference. Please give one to each of the people providing a letter. Be sure to fill in your name and school on the top of each page.

How did you learn about the AHEC of a Summer Health Careers Volunteer Program?

______

Are any members of your immediate family employed in a health care profession?

Yes ______No______

If yes, what profession? ______

Are you considering a career in health care? Yes ______No ______Unsure ______

If yes, what would you like to do?______

Have you ever worked in a health care facility as a volunteer or employee? Yes____No____

If yes, where, when, andwhat was your job?______

______

If you had a choice, which hospital department would you be most likely to volunteer in and why? Dietary Laboratory Emergency Room Occupational Therapy Nursing Radiology Physical Therapy Health Information Management Other

______

Uniform

Uniform Size InformationNote: These are in unisex sizes, please choose accordingly. Keep in mind the uniform should be loose fitting. It is better to order a little too large than too small. The scrubs come in sets. We cannot make exchanges, or mix top and bottom sizes.

Size XS S M LG XL 2X 3X
Bust/chest 35-36 37-39 40-43 44-47 48-50 51-53 54-57

Waist 26-27 28-31 32-34 35-38 39-41 42-45 46-49

Hip 37-38 39-41 42-45 46-48 49-52 53-56 57-59

What size scrub set would you like? ______

Would you like to order an additional set of scrubs? Yes_____ No_____

(one set will be provided at no charge to you. A second set is recommended as scrubs must be cleaned daily)

Cost: $14.00/setfor additional sets(do not include money with this application)

Why do you wish to participate in the AHEC of a Summer Program and what do you hope to gain from the experience?

______

Have you ever participated in any volunteer, extracurricular, or community activities? Describe and tell us what you learned from those experiences.

______

Tips For Filling Out Applications

Only use blue or black ink. Pink, purple, green, etc. are not acceptable. DO NOT write in pencil.

Do not change pens in middle of application. Looks unprofessional and doesn’t flow.

Take your time. Give thought about what you want to say before you write.

Don‘t fill it out in the last minute before a deadline.

Type in your answers unless the instructions say to hand write them.

When hand-writing an application, use your best penmanship.

Make sure your handwriting is legible. If it is hard to read, then type it. Ask another person (adult) to look at it to help you determine if you should type it.

Read your answers out loud to yourself, then to someone else. Make sure that person will be honest with you about how it sounds. Use your best grammar.

Always have at least one other person proof-read your document. It’s a good idea if that person is an adult who will be honest with you about mistakes, or how it sounds, and will give you advice. (Teacher, parent, etc.)

Do not have your parents or others fill it out. There are telltale signs that they did it.

Do not draw pictures, or dot the I’s with circles or hearts. You are writing to a professional, not to a BFF.

Do not leave blank spaces—at least write N/A (not applicable)

Check spelling. Spelling errors are UNACCEPTABLE!

Make sure to use correct forms of words. Grammar is so important! Sound smart!

Do not write like you are sending a text message. Write words out, do not abbreviate.

In essay answers, do not ramble. Be honest and tell the facts. Get to the point but sell yourself.

When answering essay questions, write it on another paper first, read it, proof it, then copy onto the final draft. Again, have another person proof your final copy.

When asked to tell something unique about you, don’t use typical answers such as, “I’m a people person” or “I like helping others.” Be specific…what makes you who you are? Tell about yourself. The question is trying to find out what makes you YOU! Do you speak 3 languages? Do you run marathons, play sports, volunteer somewhere, do something unique, or have an interesting hobby? Tell something that the other questions do not ask.

Do not type an answer on another sheet, then cut it and tape or glue it onto the application. It is better to type the question and answer on a separate sheet if you choose, then submits that sheet. Then, on the application after that question, just write “see attached.”

Do not expect your parents to call or email about it if there are questions, you do it…you are the one applying.

Let your personality come through, while sounding professional!

DON ‘T FORGET TO SIGN IT! Details matter.

Keep a Copy for yourself!

LETTERS OF REFERENCE/Teacher Recommendations

Please provide three letters of reference and teacher recommendations from the following: science teacher, one other core class teacher, and one from another source such as an employer, clergy member, etc. The letters of reference should NOT be from immediate family members or peers.

The content of the reference letters should address the following:

♦A description of the circumstances through which the student and reference are associated

(school club, church group, etc.)

♦A description of the students character traits (maturity, dependability, ability to get along with

others, enthusiasm, ability to follow direction, desire to learn, ambition, etc.)

♦A recommendation as to why the student should be selected to participate in this program

Please follow directions when completing the applications –See Tips!!!
Deliver to school counselor or mail in a sealed envelope by 2/26/16
Thanks!

Why do you wish to participate in the AHEC of a Summer Program and what do you hope to gain from the experience?

______

Have you ever participated in any volunteer, extracurricular, or community activities? Describe and tell us what you learned from those experiences.

______

Southwest Louisiana Area Health Education Center

AHEC of a SUMMER Student Volunteer Program

Teacher Recommendation Form

Applicant Name:______Current School:______

Teacher Name:______Subject:______

The above named student has applied to the 2016 AHEC of a SUMMER volunteer program and has been asked to submit this form for reference. This is an amazing opportunity for the applicant to experience Health Care Careers.

Please complete this recommendation form and return ASAP to: IPCC Nursing Teacher

Charlene Broussard RN

618 Recreation Drive

New Iberia, La. 70560

337-519-0818

The completed applications must be received by the Selection Committee no later thanFriday February 26, 2016. These forms are confidential and will not be shared with the applicant. Your open and honest communication is critical as we are placing these students in local hospitals to work with professionals.

Please check one / Excellent / Good / Fair / Poor
Punctuality
Timely Completion of Assignments
Class Participation
Social Relationship with Peers
Ability to Work in Groups
Initiative
Stays on Tasks
Character (Honesty, Attitude, etc.)
Relationship with Adults
Respect for Authority
Discipline/Behavior in Class
Please check one.
Overall Recommendation:
Highly Recommend
Recommend
Recommend with Reservations
Do NOT Recommend
Teacher Signature:
Date:

Please take a moment to comment on your personal experience with the applicant as it will be used in the selection process. You may continue on the back of this form if additional space is needed. ______

______

Southwest Louisiana Area Health Education Center

AHEC of a SUMMER Student Volunteer Program

Teacher Recommendation Form

Applicant Name:______Current School:______

Teacher Name:______Subject:______

Please complete this recommendation form and return ASAP to: IPCC Nursing Teacher

Charlene Broussard RN

618 Recreation Drive

New Iberia, La. 70560

337-519-0818

______

Southwest Louisiana Area Health Education Center

AHEC of a SUMMER Student Volunteer Program

Teacher Recommendation Form

Applicant Name:______Current School:______

Teacher Name:______Subject:______

Please complete this recommendation form and return ASAP to: IPCC Nursing Teacher

Charlene Broussard RN

618 Recreation Drive

New Iberia, La. 70560

337-519-0818

______